Rosen & Barkin's 5-Minute Emergency Medicine Consult (529 page)

• EMG:
  
  • HypoPP:
    
    • No myotonia
      
  • HyperPP:
    
    • Myotonia
      
  • Andersen–Tawil
    
• Muscle biopsy
  
• Provocative testing:
  
  • HyperPP:
    
    • Potassium and epinephrine
      
  • HypoPP:
    
    • Insulin and glucose
      

Other causes of hypokalemia or hyperkalemia

• Hyperkalemia:
  
  • Drugs: Spironolactone, ACE inhibitors, NSAIDs, heparin
    
  • Hereditary: 21-hydroxylase deficiency, McArdle disease
    
  • GI:
    
    • Ileostomy with tight stoma
      
  • Renal:
    
    • Chronic renal failure
      
  • Endocrine:
    
    • Addison disease
      
• Hypokalemia:
  
  • Drugs:
    
    • Tocolytics, amphotericin B, diuretics, reduced potassium intake, malignant hyperthermia
      
  • GI:
    
    • Vomiting
      
    • Celiac and tropical sprue
      
    • Short bowel syndrome
      
  • Renal:
    
    • Conn syndrome
      
    • Bartter/Gitelman syndrome
      
    • Acute tubular necrosis
      
    • Renal tubular acidosis
      
  • Neuromuscular:
    
    • Andersen—Tawil
      
    • Myasthenia gravis
      
  • Endocrine:
    
    • Thyrotoxicosis
      
    • Hyperaldosteronism
      
    • DKA
      

TREATMENT

• Supportive:
  
  • ABC, IV, O
    ₂
    , monitor
    

• Supportive care
  
• HyperPP:
  
  • Many attacks brief and do not need treatment
    
  • IV calcium gluconate may end attack
    
• HypoPP:
  
  • Potassium:
    
    • Preferred: Oral potassium 40 mEq
      
    • IV potassium 10 mEq 1 or 2 doses only
      
    • Watch for overcorrection
      
    • IV hydration can help correct potassium
      
• Andersen–Tawil:
  
  • Potassium unpredictable:
    
    • Could be helpful in hypokalemia
      
• ThyroPP:
  
  • Treat thyroid abnormalities:
    
    • Tachycardia: Nonselective β-blocker
      
  • Treat underlying abnormalities:
    
    • Same as in HypoPP
      
    • See the section on thyrotoxicosis
      

FOLLOW-UP

• HypoPP or HyperPP:
  
  • Lifestyle modifications:
    
    • Avoid triggers: Ethanol, prolonged exercise, high potassium foods, fasting
      
• ThryoPP:
  
  • Depends on severity of underlying disease, if asymptomatic and controlled may consider discharge with consultation with neurologist and endocrinologist.
    

• HypoPP or HyperPP:
  
  • Consider if severe hypo- or hyperkalemia, still symptomatic, cardiac or respiratory compromise
    
• Andersen–Tawil:
  
  • Admit, risk of sudden cardiac death high
    

• HypoPP, HyperPP, ThyroPP:
  
  • Resolved symptoms, referral to neurologist, no cardiac or respiratory compromise
    

• Neurology
  
• Endocrinology for ThyroPP
  
• Genetic counseling:
  
  • 50% risk of inheriting primary PP
    

• Neurology specialist in metabolic myopathies
  
• Geneticist
  

• Admit Andersen–Tawil patients and all PP patients who remain symptomatic.
  
• Use caution with volatile anesthetics and depolarizing muscle relaxants in patients with all forms of PP
  

• Alkaabi JM, Mushtaq A, Al-Maskari FN, et al. Hypokalemic periodic paralysis: A case series, review of the literature and update of management.
  Eur J Emerg Med.
  2010;17(1):45–47.
  
• Finsterer J. Primary periodic paralyses.
  Acta Neurol Scand.
  2008;117(3):145–158.
  
• Fontaine B. Periodic paralysis.
  Adv Genet.
  2008;63:3–23.
  
• Venance SL, Cannon SC, Fialho D, et al. The primary periodic paralyses: Diagnosis, pathogenesis and treatment.
  Brain.
  2006;129:8–17.
  

CODES

359.3 Periodic paralysis

BASICS

• Collection of pus in supporting structures of teeth:
  
  • Periodontal ligament
    
  • Alveolar bone
    
• Periodontal pockets result from progression of periodontal disease and resultant bone loss:
  
  • Food and debris accumulate in periodontal pockets
    
  • Coronal epithelial tissues can reattach to tooth while bacteria and food debris remain trapped in pocket, impairing drainage
    
  • Food and debris become secondarily infected in the setting of impaired drainage
    
• Complications:
  
  • Osteomyelitis
    
  • Dentocutaneous fistula
    
  • Cavernous sinus thrombosis
    
  • Ludwig angina
    
  • Maxillary sinusitis
    
  • Mediastinitis
    
  • Tooth loss
    
  • Sepsis
    

• Periodontal abscess is rare in children
  
• Periapical abscess is more common:
  
  • Originates in pulp
    
  • Associated with caries
    

• Anaerobic gram-negative rods
  
• Peptostreptococci
  
• Viridans group streptococci
  
• Neisseria species
  
• Usually polymicrobial
  

DIAGNOSIS

Periodontal abscess is a clinical diagnosis

• Dental pain
  
• Malaise
  
• Fever
  
• Facial swelling
  

• Focal swelling or fluctuance of gums and or face
  
• Tenderness to palpation
  
• Increased tooth mobility
  
• Parulis:
  
  • Pimple-like lesion on gingiva, representing terminal aspect of a sinus tract
    
  • May be seen in chronic abscess
    
• Expression of pus from sinus tract
  
• Heat sensitivity
  
• Lymphadenopathy
  
• Trismus is generally absent, unless infection has spread to muscles of mastication
  

This is a clinical diagnosis:

• Imaging and lab data are not essential for diagnosis
  

Anaerobic culture of pus:

• Complicated abscess
  
• Immunocompromised patients
  

• Panoramic, periapical, or occlusal radiographs
  
• Bedside US may also aid in confirming diagnosis
  
• CT may help visualize extension of abscess into adjacent structures
  
• Imaging can confirm and help define extent of abscess but is not essential to make diagnosis
  

Electric pulp testing:

• Performed by dental consultant to verify viability of tooth
  
• Performed during follow-up visit with dentist
  

• Periapical abscess
  
• Maxillary sinusitis
  
• Aphthous ulcers
  
• Oral herpes
  
• Salivary gland tumors
  
• Mumps
  
• Blocked salivary gland due to sialadenitis or dehydration
  
• Localized adenopathy due to oral infections
  
• Facial cellulitis
  
• Acute otitis media
  
• Peritonsillar abscess
  
• Pediatric consideration: Periapical abscess
  
• For asymptomatic parulis:
  
  • Fibroma
    
  • Pyogenic or peripheral ossifying granuloma
    
  • Kaposi sarcoma